Background Tobacco dependence disorder is a chronic relapsing condition, yet treatment is delivered in discrete episodes of care that yield disappointing long-term quit rates. Methods We conducted a randomized controlled trial from June 1, 2004, through May 31, 2009, to compare telephone-based chronic disease management (1 year; longitudinal care [LC]) with evidence-based treatment (8 weeks; usual care [UC]) for tobacco dependence. A total of 443 smokers each received 5 telephone counseling calls and nicotine replacement therapy by mail for 4 weeks. They were then randomized to UC(2 additional calls) or LC(continued counseling and nicotine replacement therapy for an additional 48 weeks). Longitudinal care targeted repeat quit attempts and interim smoking reduction for relapsers. The primary outcome was 6 months of prolonged abstinence measured at 18 months of follow-up. Results At 18 months, 30.2% of LC participants reported 6 months of abstinence from smoking, compared with 23.5% in UC (unadjusted, P=.13). Multivariate analysis showed that LC (adjusted odds ratio, 1.74; 95% CI, 1.08–2.80), quit attempts in past year (1.75; 1.06–2.89), baseline cigarettes per day (0.95; 0.92–0.99), and smoking in the 14- to 21-day interval post-quit (0.23; 0.14–0.38) predicted prolonged abstinence at 18 months. The LC participants who did not quit reduced smoking more than UC participants (significant only at 12 months). The LC participants received more counseling calls than UC participants (mean, 16.5 vs 5.8 calls; P<.001), longer total duration of counseling (283 vs 117 minutes; P<.001), and more nicotine replacement therapy (4.7 vs 2.4 boxes of patches; P<.001). Conclusion A chronic disease management approach increases both short- and long-term abstinence from smoking. Trial Registration clinicaltrials.gov Identifier: NCT00309296

Hospitalization represents a teachable moment for quitting. The current study examined predictors of quitting among hospitalized smokers. Patients reported smoking history and demographic characteristics during in-hospital baseline interviews. Discharge diagnosis also was collected. Smoking status was ascertained in interviews at 7 days and at 12 months after discharge. A total of 2,350 patients in four Minneapolis and St. Paul (Twin Cities), Minnesota, area hospitals participated in the study; 1,477 patients who provided data at both follow-ups and whose 12-month self-report of quitting was corroborated by cotinine analysis of saliva samples were included in the current analyses. Predictors of both short- and long-term abstinence in the multivariate analysis included smoking-related illness, age (those who were older were more likely to be abstinent), stage of change (precontemplators were least likely to quit, and those initially in action were most likely to quit), and time to first cigarette (those who reported smoking within 5 min of awakening were least likely to quit). The predictors presented few surprises; the most important finding may have been that the experience of hospitalization itself led to substantial long-term quitting for virtually all categories of hospitalized smokers.

Tobacco use is a serious pediatric health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Primary care settings provide tremendous opportunities for delivering tobacco treatment to young tobacco users. Although evidence-based practice guidelines for treating nicotine dependence in youths are not yet available, professional organizations and the current clinical practice guideline for adults provide recommendations based on expert opinion. This article reports on the current tobacco treatment practices of pediatric and family practice clinicians, discusses similarities and differences between adolescent and adult tobacco use, summarizes research efforts to date and current cutting-edge research that may ultimately help to inform and guide clinicians, and presents existing recommendations regarding treating tobacco use in youths. Finally, recommendations are made for the primary care clinician, professional organizations, and health care systems and policies. Pediatricians and other clinicians can and should play an important role in treating tobacco dependence in youths.

and much work needs to be done to identify the causes of regional variability. Finally, it needs to be emphasized that "fistula first" does not mean "fistula only." Patients with poor likelihood of maturation of a fistula, or a short life expectancy, may be better candidates for a graft.Complex Plaques in the Proximal Descending Aorta: An Underestimated Embolic Source of Stroke Harloff A, Simon J, Brendecke S, et al. Stroke 2010;41:1145-50. Conclusion: Retrograde flow from complex descending aorta plaques is a potential source of emboli to all brain territories.Summary: Complex aortic plaques are defined as Ն4 mm in thickness, or those associated with ulceration or that have mobile thrombi. Such plaques are considered a significant source of stroke. When such plaques are located in the ascending aorta or the aortic arch, embolization can be through antegrade flow from the aorta into a major cerebral vessel. However, the incidence of complex plaques is highest in the proximal descending aorta. Plaques in this location have only previously been considered a source of stroke in the setting of severe aortic valve insufficiency resulting in retrograde flow in the aorta during diastole. However, it now appears that diastolic retrograde flow in the descending thoracic aorta may be common in patients with atherosclerosis and therefore serve as a potentially overlooked mechanism of stroke (Svedlund S, et al, Cerebrovasc Dis 2009;27:22-8).The authors hypothesize that retrograde flow in the proximal descending thoracic aorta has the potential to reach all the supra-aortic arteries and, thus, may be a previously underappreciated source of stroke in the setting of a complex descending aorta plaque. They studied 94 consecutive acute stroke patients who had aortic plaques Ն3 mm in thickness as determined by transesophageal echocardiography. All subjects underwent magnetic resonance imaging (MRI) to localize complex plaques and to measure timeresolved 3-dimensional (3D) blood flow within the aorta. The 3D visualization was then used to determine if diastolic retrograde flow connected plaque location with origins of the left subclavian, left common carotid, or innominate artery. If retrograde flow associated with a complex descending thoracic aortic plaque reached a supra-aortic vessel that supplied the territory of an MRI-determined acute embolic retinal or cerebral infarction, the distal thoracic aortic plaque was considered a possible embolic source for the stroke.Decreasing heart rate was correlated with increasing flow reversal to the aortic arch (P Ͻ .02). Retrograde flow associated with complex proximal descending aortic plaques reached the left subclavian artery in 58.5% of cases, the left common carotid artery in 24.5%, and the brachiocephalic artery in 13.8%. Stroke etiology was determined in 57 of the 94 patients in the study and was not determined in the remaining 37 patients, so-called cryptogenic stroke. Potential embolization from a descending thoracic aortic plaque was identified in 19 of 57 patients (33.3%) wi...

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